List 3 main types of ASD

Ostium Secundum (80%) Ostium Primum (10%) Sinus venosus (10%)

What is Ostium Secundum

Confined to the region of the fossa ovalis Result from a deficiency of the septum primum to adequately close the foramen ovale Defect size ranges from a pinhole to a larger

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What is Sinus venosus

Typically at junction between the SVC and RALocated in posterior in the septum and above the superior limbic band (the superior rim of the fossa ovalis*common association with anomalous drainage of the RSPV RSPV tends to enter the LA at the junction of the SVC and RA along the right margin of the ASD. Rarely ASD can occur adjacent to the IVC and be associated with anomlaous RIPV drainage

What is unroofed coronary sinus

Direct communication between the coronary sinus and the LA Blood drains from LA through CS into the RA No actual opening in the septum Frequently a left superior vena cava draining into coronary sinus (or sometimes LA)

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Pathophysiolgy of ASD

Degree of shunting dependent on ASD size and ventricular compliance Normally PL > PR and RV more compliant so you get Left to Right shuntCauses RV dilation and excessive pulmonary flow Generally not cynaotic (only if common atrium and unroofed CS)

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What is clinical course

If significant develop RV dysfunction, Pulmonary hypertension, CHF, and usually death (often early in 3rd decade) Defects < 4 mm will usually closeDefects > 8 mm are unlikely to close Closure of any ASD after age 4 is unlikely Isolated ASD is not a risk factor for IE

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List physical signs of ASD

Audible murmur is that of physiologic pulmonic stenosis (increased flow over PVECH will show RVH, RADECHO is needed10% need a cath to look for anomalies, document pressures Common to have a 10 to 30mmHg gradient over PV

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What are the CCS 2009 guidelines for closure of ASD

Should be closed in the presence of hemodynamically significant ASD with or without symptomsA large ASD is greater then 38 mm and this should be closed surgically If pulmonary hypertension is present and reversible Qp:QS shunt of 1.5

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What are the European Class I indication for close of ASD

1) Patients with significant shunt (signs of RV overload) and a PVR < 5 should undergo closure regardless of symptoms 2) Device closure is the method of choice

IIa1) Regardless of size with suspicision of pardoxical embolism

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What are indications to close ASD

Physical symptoms of CHF Qp/Qs > 1.5 to 1. Almost all will have this if they physical signs or fixed S2 Close ASD prior to child starting school

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How is pulmonary vasculature overload tolerated

Usually pretty well (for many yers) 25% develop PHTN (with PAS > 30mmHg) Can still develop obstructive pulmonary vascular disease Increased PVR by 10% Can develop Eisenmenger's syndromeMost common cause for late mortality is CHF and arrhythmias

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What is most common complication of transcatheter closing of ASD

Most common complication with device closure are malposition and dislocation Good results when patients are selected appropriately only adequate when there is an achoring rim

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What are results of Ostium secundom defect closure

Excellent Very low peri-operative MandMLong-term survival is equal to that of age-matched cohortVery rare to need re-operation

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What are oucomes for Sinus venosus defects

SVC and RSPC stenosis is < 10% Sinus dysfunction is about 7% rare to need a PPM

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What are unique features to watch for post Ostium Primum defect repair

When should you not close an ASD

What is latest percutaneous evidence for closure of ASD to prevent paradoxical CVA

NEJM 2012--paper

In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device did not offer a greater benefit than medical therapy alone for the prevention of recurrent stroke or TIA at 2 year follow-up